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SAN JOAQUIN LOCAL HEAL'T'H DISTRICT <br /> FOR;OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> RMIT Permit No <br />� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMF, PE .k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or install the work herein described. permit to construct <br /> Joaquin <br /> County Ordinance No. 1862 and the Rules and TRegulations tofnthe an -Joaquinmade in compLocal eHealthwithSan District. <br /> JOB ADDRESS/LOCATION Xrn , <br /> CENSUS TRACT <br /> Owner's Name r <br /> Phone ' <br /> Address � A001 r7,d />_ck <br /> City <br /> Contractort.s Name / License # / Phone <br /> TYPE OF WORD (Check): NEW WELL/? DEEPEN/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP. INSTALLATION / PUMP REPAIR /-7 PUMP REPLACE , - /K7 <br /> Other <br /> Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> { <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE D(}MESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCT SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )K Domestic/private _`� Drilled Dia. of Well Casing <br /> _ <br /> IrrigatioDomestic/n <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION Contractor <br /> ---`�tt <br /> Type .of Pump <br /> H.P. <br /> PUMP R.EPI.ACEMENT LI S tate Work Done <br /> PUMP '.REPAIR: <br /> / / State Work Done . . . <br /> DES-TRUCTION OF WELT.: . Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well, in.use.. . The above <br /> information is true to-the-best af- My. , a and belief. I WILL CALL FOR A 'GROUT INSPECTION <br />'RIOR TO GROUTING 'AND A FINAL INSPECTI01� <br /> 5IGNED - % <br /> TLE <br /> D OT P ON RSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY F <br /> 0.PPLICATION ACCEPTED BY ' <br /> kDDIT.IONAL COMMENTS: DATE '.�- <br /> PHASE II GROUT INSPECTION PHA II FI INSPECTION <br /> CNSPECTIQN BY DATE INSPECTION By -z-0 <br /> -z-0 7� <br /> : <br />